Psychiatry & Infertility Double Impact: Jamal Khatib Md Consultant Psychiatrist

Psychiatry & Infertility Double impact Jamal Khatib MD Consultant Psychiatrist

Pubmed hits • Infertility

41665

• • • • • •

Infertility& psychological Infertility& depression Infertility& anxiety Infertility& stress

1016 277 199 744

Infertility quality of life Infertility emotions

152 305

Jul /57-- Dec/04 Jul /66-- Dec/04 Sep/54—Dec/04 Apri/58 -- Dec/04 Feb/74 -- Oct/04 Jun/56 -- May/04

Impact Of infertility

on Psychiatric Wellbeing

BMC Womens Health. 2004 Nov 06;4(1):9. A survey of relationship between anxiety, depression and duration of infertility. Ramezanzadeh F, Aghssa MM, Abedinia N, Zayeri F, Khanafshar N, Shariat M, Jafarabadi M. Vali-e-Asr Reproductive Health Research Center, Gynecology and Obstetrics department, Tehran University of Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz BLVD, Tehran 14194, Iran.

• This survey showed that 151 women (40.8%) had depression and 321 women (86.8%) had anxiety. Depression had a significant relation with cause of infertility, duration of infertility, educational level, and job of women. Anxiety had a significant relationship with duration of infertility and educational level, but not with cause of infertility, or job. Findings showed that anxiety and depression were most common after 4-6 years of infertility and especially severe depression could be found in those who had infertility for 7-9 years

Hum Reprod. 2004 Oct;19(10):2313-8. Epub 2004 Jul 08 Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Chen TH, Chang SP, Tsai CF, Juang KD. Department of Psychiatry, Taipei Veterans General Hospital National Yang-Ming University School of Medicine, Taipei, Taiwan

Of a total of 112 participants, 40.2% had a psychiatric disorder. The most common diagnosis was generalized anxiety disorder (23.2%), followed by major depressive disorder (17.0%), and dysthymic disorder (9.8%). Participants with a psychiatric morbidity did not differ from those without in terms of age, education, income, or years of infertility. Women with a history of previous assisted reproduction treatment did not differ from those without in depression or anxiety

Int J Fertil Womens Med. 2004 Jan-Feb;49(1):24-8. Department of Psychiatry, Faculty of Medicine, Kuwait University, Safat, Kuwait

• Compared with an age-matched pregnant control sample, the infertile women exhibited significantly higher psychopathology in all HADS parameters in the form of tension, hostility, anxiety, depression, self-blame and suicidal ideation. The illiterate group attributed the causes of their infertility to supernatural causes, such as evil spirits, witchcraft and God's retribution, while the educated group blamed nutritional, marital and psychosexual factors for their infertility. Faith and traditional healers were the first treatment choice among illiterate women, while the educated women opted for an infertility clinic for treatment. Childlessness resulted in social stigmatization for infertile women and placed them at risk of serious social and emotional consequences

Int J Fertil Womens Med. 2004 Jan-Feb;49(1):44-8. Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

• Psychological components were found to play a significant role in infertility of unknown etiology, especially in the male partner. They affected the personality and social behavior of the male partner and caused anxiety, but led to depression in the female partner. In cases of organically caused infertility, partners were worried about the other's reaction

Ceska Gynekol. 2004 Jan;69(1):42-7 [Personality and characteristics of couples in infertile marriage] Weiss P, Mateju L, Urbanek V. Sexuologicky ustav 1. LF UK, Praha..

• Men and women from infertile couples displayed moderate abnormal behavioral characteristics, men from these couples are more neurotic than general population, women display more anxiety and social desirability. The relations in these marriages are not substantially disturbed and are even less conflictuous and the consistency of the male and female roles is even better than in general population. Men from infertile couples are perceived by themselves as well as by their wives as less masculine.

Gynecol Obstet Invest. 2002;53(4):195-9. Department of Obstetrics and Gynecology, Prince of Wales Hospital, Chinese University of Hong Kong, People's Republic of China

• Our results show that one third of the women who sought infertility treatment had an impaired psychological well-being. Following failed treatment, there was a further deterioration in mental health, and about 10% of the participants were moderately to severely depressed. Proper psychological care and counseling should be an integral part of infertility management among the Chinese population

Urology. 2004 Jan;63(1):126-30. Impact of infertility on quality of life, marital adjustment, and sexual function. Monga M, Alexandrescu B, Katz SE, Stein M, Ganiats T. Department of Urology, University of Minnesota, Minneapolis, Minnesota 55455, USA

• A trend toward lower quality-of-life scores was noted in women (P = 0.09) but not in the men of infertile couples. No statistically significant impact on sexual functioning in women was noted; however, the men in the infertile couples had lower total International Index of Erectile Function scores (P = 0.05) and intercourse satisfaction scores (P = 0.03). CONCLUSIONS: Women in infertile couples reported poor marital adjustment and quality of life compared with controls. Men may experience less intercourse satisfaction, perhaps because of the psychological pressure to try to conceive or because of the forced timing of intercourse around the woman's ovulatory cycle

Impact of Psychiatry

On Infertility

Psychiatric impact mainly through effect on sexuality Male – impotence ,sperm quality Female-hormonal, vaganismus The vicious circle

Hum Reprod. 2004 Apr;19(4):954-9. Epub 2004 Feb 12. Is infertility a risk factor for impaired male fertility? Pook M, Tuschen-Caffier B, Krause W. . Department of Psychology, University of Siegen, Germany

• Analyses revealed that the level of infertility distress at follow-up has a negative impact on the change in sperm quality from baseline to follow-up assessment. Distress scores were highly stable. As a consequence, the level of distress at baseline assessment provided only little additional information for the changes in sperm concentration. Further analysis suggested that the fertility status had no impact on infertility distress. The present study delivers the strongest evidence to date that distress due to infertility is a significant risk factor for a decrease in sperm quality.

. Psychother Psychosom. 1999 Mar-Apr;68(2):95-101

•Results indicate that distress caused by infertility is a risk factor for a decrease in sperm quality.

W.H. Meller, K.M. Zander, R.D. Crosby and G.E. Tagatz, Luteinizing hormone pulse characteristics in depressed women. Am J Psychiatry 154 (1997), pp. 1454–1455

• A study of 10 depressed and 13 normal women indicated that depression is associated with abnormal regulation of luteinizing hormone . Activation of the hypothalamic-pituitary-adrenal axis can profoundly inhibit reproductive function. This inhibition of reproductive function can be at many levels, ranging from inhibition of hypothalamic GnRH to possible direct actions on the ovary and endometrium in a manner that could prevent pregnancy. Furthermore, stress and depression alters immune function and specific cytokines , which in turn could adversely affect reproductive function.

Acta Obstet Gynecol Scand. 2000 Feb;79(2):113Department of Woman and Child Health, Karolinska Hospital, Stockholm, Sweden .

• The main findings suggest that infertile women have a different personality profile in terms of more suspicion, guilt and hostility as compared to the fertile controls, perhaps as a response to their infertility. Their stress levels in terms of circulating prolactin and cortisol levels were elevated compared to the fertile controls. Psychological stress may affect the outcome of IVF treatment since state anxiety levels among those who did not achieve pregnancy were slightly higher than among those who became pregnant.

Impact

On Therapy

Gen Hosp Psychiatry. 2002 Sep-Oct;24(5):353-6. Department of Psychiatry and Behavioral Science, Tokai University School of Medicine Japan

• We investigated the effects of psychiatric group intervention on the emotions, natural-killer (NK) cell activity and pregnancy rate in Japanese infertile women by a randomized study. Thirty-seven women completed a 5-session intervention program and were compared with 37 controls. Psychological discomfort and NK-cell activity (47.7% to 34.1%, P<.0001) significantly decreased after the intervention, whereas no significant changes were observed in controls. According to a 1year follow-up of both groups, the pregnancy rate in the intervention group was significantly higher than that of controls (37.8% vs. 13.5%, P=.03). Psychological group intervention was therefore effective in Japanese infertile women.

Why do couples discontinue in vitro fertilization treatment? A cohort study Catharina Olivius, B.Sc.,a Barbro Friden, M.D., Ph.D.,b Gunilla Borg, R.N., B.S.,a and Christina Bergh, M.D., Ph.D.a Sahlgrenska University Hospital, Go¨ teborg, and Varberg Hospital, Varberg, Sweden FERTILITY AND STERILITY_ VOL. 81, NO. 2, FEBRUARY 2004

A majority of the couples (54%) who did not achieve a live birth in our study chose not to proceed through the full treatment program consisting of three completed IVF cycles. This was an unexpected finding. The reasons for discontinuing efficient treatment for infertility, free of charge, have not previously been studied in detail. In a recent publication from the Netherlands , where the cost of treatment for up to three cycles is also covered by society, the dropout rate was approximately 60% after three cycles, and those investigators concluded that economic reasons were of major importance. In our study, in which economic reasons for discontinuing treatment could be ruled out, we found that the main reason for ceasing treatment was psychological stress, followed by a poor prognosis.

Fertility and Sterility Volume 73, Issue 4 , April 2000, Pages 805-811 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA

• Women who participated in a group psychological intervention had significantly increased viable pregnancy rates compared to women who did not participate in any psychological intervention. This difference was not due to any group demographic differences, including age and duration of infertility, nor was it because of group differences in medical interventions.

Boston IVF, Waltham, Massachusetts, and Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA Fertility and Sterility Volume 81, Issue 2 , February 2004, Pages 271-273

• There have been periodic notations in the literature since the 1980s about reasons for patient dropouts, with the most commonly noted reason for dropout being financial, followed by "emotional stress • However, the reasons for voluntary withdrawal have only recently been investigated in a more extensive fashion. • In fact, the number of patients who terminate infertility treatment is significant, even when financial reasons can be discounted because of insurance coverage

…….So ?Should we interfere

Department of Obstetrics and Gynaecology, University Medical Center Radboud, Nijmegen, The Netherlands Department of Medical Psychology, University Medical Center Radboud, Nijmegen, The Netherlands

• Intervention of the mental health team could be seen as a way to lower dropout rates, but also as interference in this possibly self-protective process. The patient's mental health should indeed be considered an integral component of infertility care. Whether this leads to higher rates of treatment success, prevention of long-term depression, or lower dropout rates needs and deserves further exploration. • More attention to the psychological repercussions of infertility treatment could lead to a more personalized approach to optimize patient satisfaction. The availability of a multidisciplinary team that holistically integrates medical and mental health during the treatment period, which extends the period of regular appearances in the clinic, would be the first step

When to Interfere

Obstet Gynecol. 1999 Feb;93(2):245-51 Randolph Child and Family Counseling Center, Charlotte, North .Carolina, USA

• Because of moderate to high levels of grief and depression, therapeutic counseling may be more effective if initiated before the infertility treatment. Women's present levels of distress and coping strategies should be assessed prior to initiating infertility treatment to provide the patients with opportunities to learn and practice new adaptive behaviors that could enhance their ability to cope with infertility and the associated medical procedures.

Thank you